PERSPECTIVES: Trude Bennett

Trude Bennett, DrPH Associate professor, UNC Gillings School of Global Public Health

Editor's Note: Trude Bennett is an associate professor at the University of North Carolina's Gillings School of Global Public Health. In 2008 she spent a significant amount of time in Southeast Asia studying the effects of medical tourism on local economies and societies.   

As a health policy researcher and interested observer of transnational health services in Southeast Asia, I am frequently asked by friends and colleagues to define the term "medical tourism." Knowing that medical tourism has multiple meanings depending on context, constituency, and stakeholder, I have tried to clarify my perspective on what does and does not constitute medical tourism. My basic explanation would be the marketing of health services in receiving countries to visitors from sending countries who are traveling specifically for the purpose of seeking medical care, as well as expatriate workers living in the receiving nations. Receiving countries are usually low- or middle-income; medical travelers are usually from wealthier countries or from the upper classes of poor countries.

My specific interest is the impact of medical tourism on access to and quality of health care for local residents in countries offering foreigners “First World medical services at Third World prices.” Is this truly a “win-win” situation with unalloyed benefits for all? Some enthusiasts view healthcare as a global commodity or a form of international outsourcing; they argue for the economic rationality of shuttling patients around the globe for delivery of medical goods and services. In contrast, I see medical tourism as the “third tier” of health services, a kind of ultra-privatized care that may exacerbate the differences between public and private sectors.

Close examination of the dynamics of medical tourism, including potential benefits and harms to societies at different levels of social and economic development, is essential for ethical development of the industry. Looking beyond the individual level, does transnational healthcare offer useful models or does it simply blunt the impetus for health reform in the United States and elsewhere? Can medical tourism help remedy the current economic crisis in low- and middle-income countries struggling with plunging foreign investment and disadvantageous trade balances? And how can the potential benefits be realized?

The Asian Financial Crisis of 1997 resulted in an epidemic of empty beds in newly constructed private hospitals in Thailand and Malaysia. Recognizing the profitability of the international healthcare market, companies recruited foreign patients to fill those beds and consume a range of associated services. The relative equity and fluidity between the private and public health sectors in these countries allowed economically stressed middle-class Thais and Malaysians to shift back to public facilities without sacrificing quality of care. When private care became unaffordable, patients were willing to tolerate longer queues and greater inconvenience. Meanwhile, new clients from the United States and other countries discovered the advantages of longer stays at hospitals and rehabilitation centers: more attentive care and skilled treatment by well-trained providers at affordable cost.

Medical tourism sometimes, but not always, involves cosmetic surgery or elective treatments rarely covered under health insurance policies. In the United States and other countries struggling with containment of healthcare costs, medical necessity is becoming much harder to prove (to justify coverage) even under extreme circumstances. Quite often, medical tourism presents an option for un- or underinsured persons from industrialized countries seeking treatment of conditions that are life-threatening or compromise quality of life. For example, heart valve replacement or advanced cancer treatment may be unattainable for someone without private or public health insurance in the United States and prohibitively expensive for others with high deductibles and co-payments on their policies. International services offer an alternative to medical risk, prolonged suffering, and severe debt burden or possible bankruptcy.

Thus the notion of medical tourism cannot be reduced to frivolous globe-trotting by wealthy Westerners seeking sun, fun, and glamour. Neither can it be posed as a solution to the U.S. healthcare crisis. One of every three people under 65 in the United States lacked any form of health insurance for some part of 2007-2008, affecting all age, racial, ethnic, and income groups. Eighty percent of the uninsured were members of working families and 70 percent lived in households with at least one person employed full-time. The Institute of Medicine has estimated that lack of health insurance leads to 18,000 preventable deaths every year in the United States. Attractive as excellent and affordable healthcare in India or Thailand may be to some Americans, it is neither feasible nor desirable to address the huge gaps for medically underserved by sending them abroad. Most people are rooted in daily family and community obligations; the majority of Americans do not own passports and are not likely to travel 10,000 miles or more at a time of anxiety and discomfort. Medical tourism also represents an escalation of our huge carbon footprint and is subject to unexpected travel restrictions caused by epidemics, conflict, or threats of disruptions. Regional healthcare consortia may make sense for small contiguous nations, but surely the United States can extend a full range of services within its vast borders.

Some medical technologies are better developed and have been more quickly approved outside the United States, making treatment options abroad more expansive. In Southeast Asia patients have access to stem cell treatments not available in the United States due to ideological constraints on research in the past eight years. Even with changes under the new Administration, we have a lot of catching up to do. Such therapies can obviate the need for surgery and save both excessive cost and risk. The utilization of nonsurgical stem cell treatments in other countries offers lessons for the United States but cannot substitute for medical progress at home. Similarly, the lack of cost inflation due to uncontrolled liability insurance rates in other countries is a lesson in non-defensive medicine that should be heeded. While accountability may not be ironclad or perfect in the context of medical tourism, non-litigious strategies for mediating conflicts about medical outcomes are necessary for the functioning of the U.S. healthcare system.

Medical tourism is not necessarily an economic boon to the receiving countries, nor does it necessarily benefit local residents and guarantee them the same quality of care offered to foreigners. National economic development often increases social inequalities, and examples abound of the detrimental health effects of social disparities in income, environment, and access to resources. Medical tourism may actually drive up the cost of private care for local residents, as well as deprive patients in the public sector of providers trained at government expense.

Medical tourism as a stimulus to “internal brain drain” is clearly illustrated in Thailand and Malaysia. Both the Thai and Malaysian governments are boosting medical tourism through global advertising, tax incentives, and support for training of medical personnel in local institutions and specialty fellowships abroad. When Thailand instituted policies to promote investment in private hospitals, the exodus of doctors from government employment shot to 30 percent in 1997 (from 8 percent in 1994).

Twenty percent of Malaysia’s hospital beds -- but 54 percent of the country’s doctors --can be found in private hospitals. Chronic understaffing of nurses and doctors in Malaysia’s public facilities -- whose salaries are at least three to four times lower than their counterparts in the private sector -- will ultimately erode the quality of healthcare. Furthermore, the three-year national service requirement for all Malaysian physicians is being challenged. Those who have been practicing abroad are being lured back with promises of national service waivers. Malaysian health advocates are raising concerns that such policies may result in a lack of senior specialists to train medical students and trainees in public hospitals.

Bookman and Bookman (2007) introduced the notion of medical tourism both “crowding out” and “crowding in” public health. The profitability of medical tourism tends to “crowd out” public health, with government resources (land, financial subsidies, tax breaks) diverted to private facilities with high technology, while public health services and primary care are allowed to languish. The World Health Organization (WHO) has reported that medical tourism “may facilitate access to high-level services by the better off; but it may also divert human resources from public services to more profitable private services for the elite or foreign markets, thus reducing staffing levels, lowering staff quality, and/or raising salary costs for the public sector.” Private sector fees are also likely to rise correspondingly with the higher cost of medical tourism.

“Crowding in,” on the other hand, suggests the possibility of medical tourism’s benefits for public health through generalized economic gain and retention of doctors who might otherwise emigrate. Bookman and Bookman envision that “…a vibrant medical tourism industry can cooperate with the public sector so that nonpaying patients can make use of facilities in the private sector. This might entail the cross-subsidization of one set of patients by another with respect to shared hospital beds, medical professionals’ time and expertise, and diagnostic machinery.” Only one such example is cited: “…in Chile where private insurance companies transfer member contributions to public health insurance to pay for indigent care.” Hypothetically, profits from medical tourism could be allocated to strengthen public systems, but this Robin Hood scenario rests on an ethical imperative on the part of governments, corporations, and investors.

As a third tier of ultra-privatized healthcare, medical tourism’s influence on local access and quality of care has yet to be determined. Careful development of medical tourism, if regulated and taxed fairly, could provide revenues to ensure the sustainability and improvement of government health services. Alternatively, the danger exists for diversion of public resources to the more profitable practice of medicine for foreigners.

In Malaysia, the public sector still offers a high quality of care and choice of providers in a system that has proved remarkably effective in improving maternal health, child survival, and overall life expectancy. The key to these successes has been government commitment and financing, enabled by a strong and growing economy, and maintenance of a strong public system as a foundation for population health.

Low- and middle-income countries and transitional economies face critical choices in this time of deep crisis. Transnational healthcare offers a profitable avenue for bolstering threatened economies, but a recent Oxfam International report cites an important reminder that “No low- or middle-income country in Asia has achieved universal or near-universal access to healthcare without relying solely or predominantly on tax-funded public delivery.” Medical tourism could be harnessed as a source of funding to strengthen public services, but only if decisive government action is joined with strong corporate responsibility.

Trude Bennett, DrPH
Associate Professor
Department of Maternal and Child Health
Gillings School of Global Public Health
The University of North Carolina at Chapel Hill
Chapel Hill, NC 27599-7445
Phone: (919) 966-5977
Fax:  (919) 966-0458
trude_bennett@unc.edu

About Trude Bennett
Trude Bennett, MSW, MPH, DrPH is Associate Professor of Maternal and Child Health at the Gillings School of Global Public Health, The University of North Carolina at Chapel Hill. She has been working in various locations in Southeast Asia over the last decade, and spent part of Summer 2008 studying medical tourism in Thailand and Malaysia.